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Critics say the College of Physicians and Surgeons should automatically inform hospitals of sanctions, but doctors ask how much patients need to know.

Dr. Jack Barkin, listed on Humber River Hospital's website as the chief of staff, received an oral caution from the provincial medical watchdog after Barkin performed a minor, elective surgery on a patient who later died.

Michael Green, 91, died last year of a stroke. He was under the care of Dr. Jack Barkin, who performed minor elective surgery on Green a little more than a week before he died. Green's family complained to the College of Physicans and Surgeons of Ontario, believing Green's stroke and death were related to his surgery. (Family photo)

Dianne Green holds a photo of her husband, 91-year-old Michael Green, who died last year, as her son Jeff looks on. They filed a complaint with the College of Physicians and Surgeons about two doctors who operated on Michael last year about a week before he died. The college secretly issued an oral caution to Dr. Jack Barkin, who is also the chief of staff at Humber River. (Steve Russell / Toronto Star)

Humber River Hospital’s top doctor has run into trouble with the province’s medical watchdog over the care he provided involving minor, elective surgery to a patient who later died.

The College of Physicians and Surgeons of Ontario has imposed on chief of staff Dr. Jack Barkin an “oral caution” — a higher level disposition intended as remedial rather than punitive, aimed at giving him direction “to avoid future difficulties.”

But you’re not supposed to know that.

The only reason the Star found out that Barkin has been cautioned is that the paper was contacted by the family of an elderly patient who died last year after being under his care.

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This case highlights the systemic problems behind the college’s current practice of keeping secret anything less than the most serious allegations, which can lead to findings of misconduct or incompetence.

The family of 91-year-old Michael Green shared with the Star a written college decision on a complaint they filed against Barkin. Marked “private and confidential,” the June 4 decision identifies problems with his clinical care, but does not say the urologist was responsible for Green’s death.

The decision states that Barkin has a “previous history where the college has taken action with respect to prior clinical complaints.” This elevated the CPSO’s concern about the doctor’s clinical care of Green and contributed to a decision to orally caution him.

The decision offers no details about the 61-year-old physician’s history of complaints, including the number and seriousness of them. That information is kept secret by the college, even from hospitals, unless the doctors who are cautioned reveal it themselves.

In this case, Humber’s chief operating officer, Barbara Collins, says Barkin was forthcoming about his recent caution. But she did not respond to repeated questions about whether he informed the hospital of the “prior clinical complaints” that resulted in the college taking action against him.

Medical malpractice lawyer Paul Harte says the college should automatically inform hospitals when doctors have been sanctioned.

“The board of directors at the Humber River Hospital should join in the call for greater transparency. It is difficult to accept that the board of a public hospital is not currently entitled to obtain direct disclosure from the college of the clinical concerns regarding their chief of staff.”

In the last two years, the college has imposed 619 cautions, most of them resulting from public complaints. Of those, 435 were “written” rather than “oral” and considered much less severe. They are kept permanently on doctors’ records, but not posted under their public profiles on the college’s online register.

Last year, a Star investigation revealed that the province’s 21 health regulatory colleges issued 2,205 oral and written cautions to health-care workers between 2007 and 2011. There are approximately 267,000 regulated health-care professionals in Ontario, including psychologists, massage therapists, optometrists, midwives and physiotherapists.

The CPSO wants to lift the veil of secrecy, at least somewhat. It is two years into a “transparency project” that aims to help patients make more informed choices about what doctors they see. Proposals include posting online whether a doctor has been orally cautioned or has a criminal record.

The hospital sector is among the proponents of more transparency. Hospitals want to know if the college has imposed cautions on any of their doctors. Barkin’s own hospital is in favour of making cautions public.

“In an era of increased transparency, the college should inform any hospital where a physician has privileges of cautions issued to the physician, and also make this information public,” Collins says.

But there is resistance to the transparency project from the medical profession because of concerns that patients may not fully appreciate the nuances of information disclosed and that doctors’ reputations could suffer.

Green, a retired tailor, saw Barkin last year on Aug. 8 for a minor, elective surgical procedure known as a cystoscopy to correct a urethral stricture. The urethra in his penis was narrowed, making it difficult to completely empty his bladder and causing him to wake frequently during the night to urinate.

But during a preoperative electrocardiogram, it was discovered that Green was in atrial fibrillation, meaning his heart was beating irregularly.

Barkin and anesthesiologist Dr. James Young discussed whether to cancel the surgery given that Green’s heart was beating at a rapid 155 beats per minute, according to written accounts that the two doctors provided the CPSO and that were later obtained by the Star.

But they judged it was safe to proceed because Green showed no symptoms from the rapid heart rate, because it would be a quick, minor procedure with minimal stress and because he would be sedated rather than given a general anesthetic. They also expressed concern that holding off on the cystoscopy could lead to other problems.

The outpatient surgery seemed to have gone well and Green went home later that day. But two days later he suffered a stroke and seven days after that he died.

Green’s family complained to the CPSO about the two doctors, believing his stroke and death were related to the surgery. They feel it should have been cancelled because of his irregular heart rhythm.

Barkin, an associate professor at the University of Toronto’s medical school and a director of the Society of Urologic Surgeons of Ontario, defended his decision to go ahead with the surgery in his written account:

“I stand by my judgment that it was appropriate to perform the procedure given his urinary symptoms . . . I do not believe that the brief urethral dilation I performed caused his stroke.”

Young wrote: “Hindsight is 20/20 and in retrospect, I wish I had requested an urgent cardiology consult.”

In the end, the CPSO’s Inquiries, Complaints and Reports Committee said the cystoscopy “was obviously not urgent” and could have waited.

“The fact that this (atrial fibrillation) was a new diagnosis seems to have been totally ignored by Dr. Barkin. And to reiterate, this was an elective procedure,” the decision states.

“Mr. Green was at constant risk of sudden death from his AFib,” which is a known precursor to stroke, the document says. The urologist should have been “more cautious” and obtained a cardiology consultation.

The decision also quotes cardiologist Dr. Louis Yao, who treated Green after the stroke, as saying the cystoscopy likely had little to do with the stroke, which could have happened at any time.

The committee gave Barkin three months to research the literature on how patients like Green should be managed and to write a paper on what he learned. Committee members plan to discuss it with him when he appears for his oral caution.

A less severe disposition was handed down to Young. The committee issued him a written caution, saying he should have obtained a cardiology consultation.

In going easier on the anesthesiologist, the committee wrote: “Dr. Young has only one previous complaint at the college, on which the college took no action, so his history at the college is non-concerning.”

Harte says the CPSO’s decision reflects “a very serious level of concern” with the care provided by Barkin and raises big questions about patient safety.

“Unfortunately, due to the lack of transparency in the college complaints process, the public can only speculate on the magnitude of the problem. The fact that this physician holds the position of chief of staff at a major public hospital makes the potential danger to the public all the more acute.”

Harte points out that as chief of staff, Barkin would have chaired the hospital’s medical advisory committee, which is responsible for upholding the quality of care provided by doctors.

“As chief of staff, Dr. Barkin is responsible for ensuring that all doctors at Humber River Hospital are practising at the highest levels. With his own clinical skills under question, his ability to lead will presumably be impaired. In the end, the public should not have to guess about Dr. Barkin’s qualifications, nor should Dr. Barkin be subject to unfair speculation,” he says.

Requests were made to both doctors for interviews. Young did not respond.

In a July 15 email, Barkin said he would talk to a reporter the following day if the Green family signed a release, waiving confidentiality rights. A release was sent, but Barkin never got back to the paper.

Barkin’s lawyer Chris Wayland sent an email on July 21, expressing concern that the Star was in possession of the CPSO’s decision to caution the doctor.

“It would appear that you have a document that is confidential and not on the public record. We are currently considering our position with respect to the lawfulness of the Star’s possession and proposed publication of this document and I hope to get back to you shortly.”

Wayland did not get back to the paper.

On Wednesday, Humber’s communication’s director Gerard Power sent this email:

“Dr. John Hagen is currently acting chief of staff. Dr. Barkin has been on medical leave since June 19th. He was up for reappointment as chief of staff and for medical reasons has decided not to seek reappointment.”

Barkin’s medical leave took effect two weeks after the college’s ruling.

Citing an appeal of the CPSO decision by the Green family, the hospital did not respond to repeated questions about when exactly Barkin, who had been chief of staff since 2007, resigned.

There is much debate over how much information should be made available to patients about their doctors.

For more than a century, the college held closed disciplinary hearings to deal with cases in which there was evidence that doctors had made very serious clinical errors or abused patients.

“When the decision was made in 1991 to hold the disciplinary hearings in a public forum, there was much trepidation. ‘Air our dirty laundry? Too revealing, too unseemly,’ said some worried members of the profession,” CPSO registrar Dr. Rocco Gerace writes in the most recent issue of the college’s publication Dialogue.

“Looking back now, it seems inconceivable that such a process was ever held away from the public’s eye,” he adds.

The college’s transparency project was launched in recognition that it was time to re-evaluate the balance of public reporting and physician privacy, Gerace says, adding that there is worldwide recognition that public institutions need to make more information available.

Last year, the college began making public the results of inspections of “out-of-hospital premises,” such as private colonoscopy and plastic surgery clinics. This came following revelations in the Star that the college was not publicly identifying clinics that failed, thereby placing the public at risk.

The CPSO’s governing council is expected to decide in September whether to reveal on its public register whether physicians have criminal records or bail conditions that are relevant to the practice of medicine.

And the CPSO, along with some of the other health regulatory colleges, soon plans to begin consultations on a proposal to go even further and make public whether health professionals have had oral cautions, have been ordered to take continuing education courses or have signed “undertakings” for example, to cease practising or abide by practice restrictions.

“We are taking these steps to be more accountable to the public and it is the public interest that we represent,” Gerace said in an interview, adding that the college is already one of the most transparent medical regulators in the world.

But there is concern among doctors about how much patients need to know and whether they could fully appreciate the information that would be disclosed.

The Ontario Medical Association, which represents the province’s 25,000 doctors, warned in a submission to the CPSO last year: “The current discussion about what information a regulatory college should make available to the public must also give serious consideration to the potential for misinterpretation of limited or decontextualized information and the potential for irreparable (and unwarranted) harm to a member’s reputation.”

“OTLA feels that the overriding concern in establishing and applying these transparency principles must be, first and foremost, the protection of the public and disclosure of information, not the protection of the physician’s privacy.”

In Harte’s opinion, the transparency project isn’t even going far enough. The college is not proposing, for example, that written cautions be made public, he notes.

“The college’s lack of disclosure is a disservice to both the public and the medical profession,” he says.

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